The use of opioids for pain relief in work compensation continues to decline, replaced by non-steroidal anti-inflammatory drugs, muscle relaxants and dermatologicals. And while the industry praises the decline in opioid prescribing, the increase in the use of the more expensive alternatives is causing concern.
According to recently released preliminary data from the Workers Compensation Research Institute, the payment rate for opioids in 28 study states decreased to 8% in the first quarter of 2020 from 21% in the first quarter of 2015. Meanwhile, the rate of payments for dermatological drugs decreased to 21% from 11 % during the same time period, and the payment rate for non-steroidal anti-inflammatory drugs increased to 1
In California, NSAIDs accounted for nearly 24% of total drug costs in 2020, compared with 14% in 2018, when the state's drug form went into effect, according to research from the California Workers' Compensation Institute.
Two expensive drugs – phenoprofen and ketoprofen – which are exempt from future use reviews, accounted for more than a quarter of NSAID drug spending in the state by 2020, even though they represented only 1% of NSAIDs.
"These are older drugs … drugs that have been on the market since I went to medical school 30 years ago," said Dr. Craig Ross, Bala Cynwyd, Pennsylvania-based medical director of Liberty Mutual Holding Co. Inc "Why doctors choose them right now is a little confusing to me. I do not know that there is any great advantage to any of them over other NSAIDs."
The reason for the high price is just as confusing, says Dr. Ross. In California, the average amount of a prescription for phenoprofen calcium was $ 1,479 in 2020 – an increase of 636% over the average fee in 2016, and the average amount of ketoprofen in 2020 was $ 1,097, an increase of 11 times from $ 99 in 2016, according to CWCI.
"In our business book, we reduced that 70% of (phenoprofen) prescriptions come from three doctors," said Phil Walls, Tampa, Florida-based clinical director of myMatrixx, an Express Scripts company. “Three generic companies that we have identified charge an average wholesale price per pill higher than the original branded drug Nalfon. All that is required are some bad actors to completely disrupt the system and drive outrageous costs.
While Ryan Hamm, Dublin, Ohio-based clinical pharmacist for CorVel Corp., said the increased use of NSAIDs is not surprising given that physicians should find alternatives to opioids for pain relief, he also questions the reasons for the increased prescribing phenoprofen and ketoprofen in California.
"I do not know why they pick (these) drugs in front of others," Hamm said. "When we talk pharmacologically, there is not much difference between NSAIDs, only small differences in how fast they work."
Another major source of cost for workers' compensation for drug costs is private labels, such as creams, gels and ointments, which are independently manufactured and not recommended based on evidence-based guidelines. These have "a much higher price tag" than comparable products approved by the official guidelines for Disabled Workers' Compensation Drug Formulary, also known as ODG, says Vennela Thumula, policy analyst for Cambridge, Massachusetts-based WCRI.
Private label subjects "present some inherent challenges," said Silvia Sacalis, vice president of clinical services at Tampa, Florida-based Healthesystems LLC. "They are not approved by the U.S. Food and Drug Administration, so there are no clinical studies showing safety and efficacy."
In addition, doctors who release labels of current substances bypass typical pharmacy checks because they relate to drug and disease interactions, she said.
“Because most of them get doctors, it means they are not going through the right channels. They skip many checks and balances because the injured worker does not get the medicine from a pharmacy, says Reema Hammoud, Southfield, Michigan-based Deputy Vice President of Clinical Pharmacy for Sedgwick Claims Management Services Inc.
Miss. Hammoud noted that most private labels are drugs that have higher potency than existing drugs – many of which are cheap, over-the-counter drugs.
"If you think about it, if something was really that beneficial, the FDA would approve it and it would be manufactured by drug companies," Hammoud said.
One question is that many doctors do not know the cost of the drugs they dispense, Hamm said.
"If you do not tell them, most people will probably not know what the drug costs are," he said. “That is why I think it is so important to have that communication aspect and the outreach; sometimes they really do not know. "
Forms and user reviews are also effective ways to reduce the prescribing of expensive or non-evidence-based drugs, even if there are restrictions," says Sacalis.
Another issue is that forms do not always account for fluctuating costs, and that is "where things can go up and down," she said.
Although some states like California have robust forms, "there will always be loopholes," Sacalis said.